Mollusc and crustacean consumption in the first 1000 days: a scoping review.

Mollusc and crustacean consumption in the first 1000 d may improve maternal and child health by providing essential nutrients. However, in some contexts, molluscs and crustaceans have been associated with allergies and environmental contamination, potentially leading to adverse health and development outcomes. It is unclear whether the health benefits of consuming molluscs and crustaceans, collectively classified as shellfish in nutrition, are outweighed by the potential risks to pregnant women and children. We conducted a scoping review (PROSPERO: CRD42022320454) in PubMed, Scopus and EBSCO Global Health of articles published between January 2000 and March 2022 that assessed shellfish consumption during pregnancy, lactation or childhood (0-2 years) in relation to maternal health, child health or child development. A total of forty-six articles were included in this review. Overall, shellfish consumption was associated with higher biomarkers of environmental contaminants, with mercury being the most studied and having the strongest evidence base. The limited research on nutritional biomarker status shows an association between shellfish consumption and iodine status. Preterm birth was not associated with shellfish consumption, but newborn anthropometry showed mixed results, with several studies reporting lower birth weight with higher shellfish consumption. The few studies that examined child development and maternal health outcomes reported no significant associations. This review revealed trade-off health risks and benefits with inclusion of molluscs and crustaceans in the dietary patterns of mothers and young children. More research is needed to understand how these aquatic animal-source foods may be safely consumed and leveraged for improving human nutrition.

Associations of fish and meat intake with iron and anaemia in Malawian children.

Animal flesh foods are rich in bioavailable iron but infrequently consumed by young children. We aimed to determine whether flesh food intake was associated with iron and anaemia status among 585 Malawian infants enroled in a 6-month egg-feeding trial. The percentage of days of small fish, large fish and meat consumption were assessed through weekly 7-day animal-source food screeners. Grams of intake were assessed through 24-h recalls conducted at 6-9, 9-12 and 12-15 months of age. Plasma ferritin, soluble transferrin receptor (sTfR) and haemoglobin concentrations were measured at 6-9 and 12-15 months of age. Iron biomarkers were adjusted for inflammation during analysis. At enrolment, each flesh food category was consumed by <5% of children in the past 24 h. Over the next 6 months, small fish, large fish and meat were consumed on 25%, 8% and 6% of days, respectively, with mean usual intakes of <5 g/day. More frequent small fish consumption was associated with lower sTfR (geometric mean ratio [95% CI]: 0.98 mg/L [0.96, 1.00] per 10 percentage point difference) but not ferritin (1.03 µg/L [0.98, 1.07]) or haemoglobin (1.01 g/dL [1.00, 1.01]). Large fish consumption was associated with higher anaemia (prevalence ratio [95% CI]: 1.09 [1.01, 1.19]) and lower iron deficiency (0.96 [0.93, 1.00]) prevalence. Gram intakes of flesh food categories were not associated with any iron or anaemia indicators. Small fish were a primary contributor to flesh food intake in this cohort of Malawian children, although usual portions were small. Fish was associated with modest improvements to iron status, but meat was too infrequent to be associated with anaemia and iron deficiency.

Sensory panel results of a dried fish powder supplement among caregivers and young children in Zambia.

OBJECTIVE: To evaluate the acceptability of traditional Zambian dishes fortified with Complementary Food for Africa+Dried Fish Powder (ComFA+Fish), a locally sourced protein/micronutrient blend designed to impact nutrient deficiencies among infants and young children (IYC) and improve pregnancy and birth outcomes among women of reproductive age (WRA). DESIGN: During two sensory panels, caregivers evaluated: (1) the acceptability of four ComFA+Fish dishes for household consumption, including fortified chibwabwa fisashi, savory Kapenta chutney, fortified complementary maize porridge and fortified bean-vegetable soup and (2) whether their IYC found the fortified complementary maize porridge acceptable. SETTING: Lake Kariba, Southern Province, Zambia. PARTICIPANTS: Women of reproductive age (n 42) and their IYC aged 6-11 months (n 16) and 12-23 months (n 26) were recruited from fishing villages in Gwembe, Siavonga and Sinazongwe District. RESULTS: A majority of caregivers extremely liked/liked the: (1) fortified chibwabwa fisashi's sensory attributes (94·7 %), convenience (92·8 %) and overall acceptability (100 %); (2) savory Kapenta chutney's sensory attributes (81·8 %), convenience (92·8 %) and overall acceptability (100 %); (3) fortified complementary porridge's sensory attributes (83·5 %), convenience (90·5 %) and overall acceptability (88·1 %) and (4) fortified bean-vegetable soup's sensory attributes (66·8 %), convenience (87·5 %) and overall acceptability (87·5 %). Further, a majority of caregivers evaluated the fortified complementary porridge as highly acceptable to their IYC. CONCLUSIONS: Results suggest that ComFA+Fish is strategically well placed to fill nutritional gaps among IYC and WRA in Zambia and has the potential to be scaled across sub-Saharan Africa.

Seroprevalence Study of Conserved Enterotoxigenic Escherichia coli Antigens in Globally Diverse Populations.

Enterotoxigenic Escherichia coli (ETEC) are common causes of infectious diarrhea among young children of low-and middle-income countries (LMICs) and travelers to these regions. Despite their significant contributions to the morbidity and mortality associated with childhood and traveler's diarrhea, no licensed vaccines are available. Current vaccine strategies may benefit from the inclusion of additional conserved antigens, which may contribute to broader coverage and enhanced efficacy, given their key roles in facilitating intestinal colonization and effective enterotoxin delivery. EatA and EtpA are widely conserved in diverse populations of ETEC, but their immunogenicity has only been studied in controlled human infection models and a population of children in Bangladesh. Here, we compared serologic responses to EatA, EtpA and heat-labile toxin in populations from endemic regions including Haitian children and subjects residing in Egypt, Cameroon, and Peru to US children and adults where ETEC infections are sporadic. We observed elevated IgG and IgA responses in individuals from endemic regions to each of the antigens studied. In a cohort of Haitian children, we observed increased immune responses following exposure to each of the profiled antigens. These findings reflect the wide distribution of ETEC infections across multiple endemic regions and support further evaluation of EatA and EtpA as candidate ETEC vaccine antigens.

The Effects of One Egg Per Day on Vitamin A Status Among Young Malawian Children: A Secondary Analysis of a Randomized Controlled Trial.

Background: Vitamin A deficiency (VAD) is common in populations with limited dietary diversity and access to vitamin A-rich foods. Objectives: This analysis aimed to determine the impact of supplementing children's diets with 1 egg/d on the concentration of plasma retinol and RBP and the prevalence of VAD. Methods: Children age 6-9 mo living in the Mangochi district of Malawi were individually randomly assigned to receive 1 egg/d for 6 mo (n = 331) or continue their usual diet (n = 329) in the Mazira trial (clinicaltrials.gov; NCT03385252). This secondary analysis measured plasma retinol by HPLC and RBP, CRP, and α-1-acid glycoprotein (AGP) by ELISA techniques at enrollment and 6 mo follow-up. Retinol and RBP were adjusted for inflammation, and mean concentrations were compared between groups using linear regression models. In addition, prevalence ratios of VAD (retinol <0.7 µmol/L) were compared between groups using log-binomial or modified Poisson regression models. Results: After 6 mo of study participation, 489 were assessed for retinol (egg: n = 238; control: n = 251), and 575 (egg: n = 281; control: n = 294) were assessed for RBP. Prevalence of inflammation (CRP >5 mg/L or AGP >1 g/L: 62%) and inflammation-adjusted VAD (7%) at enrollment did not differ between groups. At follow-up, the egg intervention group did not differ from the control in inflammation-adjusted retinol [geometric mean (95% CI); egg: 1.10 µmol/L (1.07, 1.13); control: 1.08 (1.05, 1.12)], RBP [egg: 0.99 µmol/L (0.96, 1.02); control: 0.97 (0.94, 1.00)], or prevalence of VAD [egg: 6%; control: 3%; prevalence ratio: 1.87 (0.83, 4.24)]. Conclusions: Provision of 1 egg/d did not impact VAD, plasma retinol, or RBP among young children in rural Malawi, where the prevalence of VAD was low. Curr Dev Nutr 2023;x:xx.This trial was registered at [clinicaltrials.gov] as [NCT03385252].

Prevalence of diarrheagenic Escherichia coli and impact on child health in Cap-Haitien, Haiti.

BACKGROUND: Diarrheagenic Escherichia coli (DEC) are common pathogens infecting children during their growth and development. Determining the epidemiology and the impact of DEC on child anthropometric measures informs prioritization of prevention efforts. These relationships were evaluated in a novel setting, Cap-Haitien, Haiti. METHODS: We performed pre-specified secondary analysis of a case-control study of community-dwelling children, 6-36 months of age, enrolled 96 cases with diarrhea and 99 asymptomatic controls. Assessments were performed at enrollment and one month later at follow-up. Established endpoint PCR methodologies targeted DEC gDNA isolated from fecal swabs. The association between DEC and anthropometric z-scores at enrollment was determined using multivariate linear regression. Lastly, we assessed the association between specific biomarkers, choline and docosahexaenoic acid (DHA) and diarrheal burden. RESULTS: Enterotoxigenic Escherichia coli (ETEC) was identified in 21.9% of cases vs. 16.1% of controls with heat-stable producing ETEC significantly associated with symptomatic disease. Enteroaggregative E. coli (EAEC) was found in 30.2% of cases vs. 27.3% of controls, and typical enteropathogenic E. coli in 6.3% vs. 4.0% of cases and controls, respectively. Multivariate linear regression, controlled for case or control status, demonstrated ETEC and EAEC were significantly associated with reduced weight-age z-score (WAZ) and height-age z-score (HAZ) after adjusting for confounders. An interaction between ETEC and EAEC was observed. Choline and DHA were not associated with diarrheal burden. CONCLUSIONS: DEC are prevalent in north Haitian children. ETEC, EAEC, household environment, and diet are associated with unfavorable anthropometric measures, with possible synergistic interactions between ETEC and EAEC. Further studies with longer follow up may quantify the contribution of individual pathogens to adverse health outcomes.

Ultra-processed foods in a rural Ecuadorian community: associations with child anthropometry and bone maturation.

Frequent ultra-processed food (UPF) consumption is consistently associated with poor health outcomes. Little is known about UPF intake during early childhood and its effects on growth. We assessed UPF in relation to child anthropometry, bone maturation, and their nutrition profiles in a rural Ecuadorian community. Covariate-adjusted regression models estimated relationships between UPF intake from a 24-hour Food Frequency Questionnaire and three outcomes: linear growth, weight status and bone maturation. Nutrient Profiling Models (NPM) evaluated a convenience sample of UPF (n 28) consumed by children in the community. In this cohort (n 125; mean age = 33·92 (sd 1·75) months), 92·8 % consumed some form of UPF the previous day. On average, children consuming UPF four to twelve times per day (highest tertile) had lower height-for-age z-scores than those with none or a single instance of UPF intake (lowest tertile) (ß = -0·43 [se 0·18]; P = 0·02). Adjusted stunting odds were significantly higher in the highest tertile relative to the lowest tertile (OR: 3·07, 95 % CI 1·11, 9·09). Children in the highest tertile had significantly higher bone age z-scores (BAZ) on average compared with the lowest tertile (ß = 0·58 [se 0·25]; P = 0·03). Intake of savoury UPF was negatively associated with weight-for-height z-scores (ß = -0·30 [se 0·14]; P = 0·04) but positively associated with BAZ (ß = 0·77 [se 0·23]; P < 0·001). NPM indicated the availability of unhealthy UPF to children, with excessive amounts of saturated fats, free sugars and sodium. Findings suggest that frequent UPF intake during early childhood may be linked to stunted growth (after controlling for bone age and additional covariates), despite paradoxical associations with bone maturation.

Friend or Foe? The Role of Animal-Source Foods in Healthy and Environmentally Sustainable Diets.

Scientific and political discussions around the role of animal-source foods (ASFs) in healthy and environmentally sustainable diets are often polarizing. To bring clarity to this important topic, we critically reviewed the evidence on the health and environmental benefits and risks of ASFs, focusing on primary trade-offs and tensions, and summarized the evidence on alternative proteins and protein-rich foods. ASFs are rich in bioavailable nutrients commonly lacking globally and can make important contributions to food and nutrition security. Many populations in Sub-Saharan Africa and South Asia could benefit from increased consumption of ASFs through improved nutrient intakes and reduced undernutrition. Where consumption is high, processed meat should be limited, and red meat and saturated fat should be moderated to lower noncommunicable disease risk-this could also have cobenefits for environmental sustainability. ASF production generally has a large environmental impact; yet, when produced at the appropriate scale and in accordance with local ecosystems and contexts, ASFs can play an important role in circular and diverse agroecosystems that, in certain circumstances, can help restore biodiversity and degraded land and mitigate greenhouse gas emissions from food production. The amount and type of ASF that is healthy and environmentally sustainable will depend on the local context and health priorities and will change over time as populations develop, nutritional concerns evolve, and alternative foods from new technologies become more available and acceptable. Efforts by governments and civil society organizations to increase or decrease ASF consumption should be considered in light of the nutritional and environmental needs and risks in the local context and, importantly, integrally involve the local stakeholders impacted by any changes. Policies, programs, and incentives are needed to ensure best practices in production, curb excess consumption where high, and sustainably increase consumption where low.

Associations between livestock keeping, morbidity and nutritional status of children and women in low- and middle-income countries: a systematic review.

Livestock keeping can positively influence the nutritional status of populations and households through increased consumption of animal-source foods (ASF) and other indirect pathways, but can also adversely affect health by increasing the risk of diseases. We conducted a systematic review synthesising the current state of knowledge on the associations among livestock keeping, infectious disease and the nutritional status of children under 5 years and women of reproductive age in low- and lower-middle-income countries (LMICs). A comprehensive search of 12 electronic databases and grey literature sources published from 1991 to the end of December 2020 was conducted. Investigations exploring relationships between livestock keeping and risk of infectious disease transmission and nutritional status were selected using pre-defined inclusion criteria. After screening and filtering of 34,402 unique references, 176 references were included in the final synthesis. Most (160/176, 90.1%) of the references included in the final synthesis were from sub-Saharan Africa (SSA) and Asia. About two out of every five (42%) studies reviewed showed that livestock production is associated with improved height-for-age Z scores (HAZ) and weight-for-length/height Z scores (WHZ), while close to a third (30.7%) with improved weight-for-age Z scores (WAZ). Similarly, livestock production showed a positive or neutral relationship with women's nutritional status in almost all the references that reported on the topic. Conversely, four-fifths (66/81, 79.5%) of the references reporting on infection and morbidity outcomes indicated that livestock keeping is linked to a wide range of infectious disease outcomes, which are spread primarily through water, food and insects. In conclusion, in many LMIC settings, livestock production is associated with better nutritional outcomes but also a higher risk of disease transmission or morbidity among women and children.This review was prospectively registered on PROSPERO 2020 [CRD42020193622].

Samaki Salama - Promoting healthy child growth and sustainable fisheries in coastal Kenya: A study protocol.

Background: One in five young children globally suffer the consequences of stunted growth and development and millions experience deficiencies in zinc, iron, iodine, vitamins A and B12, nutrients found bioavailable in fish foods. Small-scale fisheries have the potential to generate income and augment fish consumption while being environmentally sustainable if appropriately managed. However, those engaged in small-scale fisheries are often marginalized, poor, and malnourished. The Samaki Salama project seeks to better understand and address these challenges through a three-arm, longitudinal matched cluster study which evaluates the impact of an integrated nutrition social marketing and modified fishing trap intervention. Methods: There will be 400 small-scale fisher households enrolled from Kilifi County, Kenya and residing in communities matched on location (rural), livelihoods, and child nutritional status. The sample will include mothers and other caregivers, children 6-60 months, and fishers in the family. Applying a cluster design, the matched communities will be divided into three groups: (1) control (n = 200); (2) multi-component nutrition social marketing intervention to fishers, mothers, and health workers (n = 100); and (3) multi-component nutrition social marketing intervention plus modified fishing traps and training (n = 100). Primary outcomes include child growth, fish food intakes, and fisheries yield of mature fish. Secondary outcomes are diet diversity, child diarrheal morbidity, and fisheries revenue. A process evaluation will be used to monitor and ensure fidelity of intervention delivery. Discussion: This study builds on a growing body of literature illustrating the effectiveness of nutrition focused social marketing campaigns to promote active engagement of participants, high compliance to the intervention, and sustained behavior change. The second intervention element of modified fishing traps that allow immature fish to escape enables participants to act on the messaging they receive and promotes sustainable fishing through increased harvest efficiency and reduced catch of immature fish. The integrated approach of the Samaki Salama intervention provides an example of how to leverage multiple disciplines to address key challenges to human and environmental health and illustrates a pathway for scaling study innovations to other small-scale fisheries systems. Trial registration: https://clinicaltrials.gov (NCT05254444).

Choline, DHA, and Diarrheal Disease Associated with Growth Faltering in a Case-Control Study.

Background: Children with recurrent infectious diarrhea are susceptible to growth faltering. DHA and choline may play a role in this relationship due to their involvement in lipid metabolism, gut immunity, and inflammatory pathways. Objectives: This study aimed to characterize the contributions made by DHA and choline status and enteric damage in young children in the association between diarrheal illness and child growth. Methods: A longitudinal case-control study was conducted among children aged 6-36 mo (N = 195) in Cap-Haitien, Haiti. Mother-child dyads were recruited from community health posts and outpatient clinics. Cases were defined as children experiencing acute diarrhea within the last 3 d and matched to healthy controls. Child anthropometry, dietary intake, and blood and stool samples were collected at baseline and follow-up. Plasma DHA, choline, and betaine were determined by LC-MS/MS methods (n = 49) and intestinal fatty acid-binding protein (I-FABP) by ELISA (n = 183). Multivariate regression models were applied with mediation analyses to examine associations and adjust for confounding factors. Results: At baseline, mean plasma DHA concentrations (1.03 µg/mL; 95% CI: 0.91, 1.15) were not significantly different between cases and controls, nor was there a difference in mean plasma choline concentrations (4.5 µg/mL; 95% CI: 3.8, 5.1). Mean plasma I-FABP concentrations were significantly higher at follow-up in cases (3.34; 95% CI: 3.28, 3.40) than controls (3.20; 95% CI: 3.13, 3.27; P = 0.002). In adjusted multilinear regression models, higher plasma DHA concentrations at follow-up were associated with a negative change in weight-age z score (P = 0.016), and follow-up I-FABP was inversely associated with height-age z score (P = 0.035). No interaction or mediation effects were found. Conclusions: I-FABP concentrations were significantly higher in cases as compared with controls at follow-up, suggesting ongoing enteric damage and increased risk for malnutrition. Plasma DHA and I-FABP may have a role in childhood growth outcomes.

Preventive small-quantity lipid-based nutrient supplements reduce severe wasting and severe stunting among young children: an individual participant data meta-analysis of randomized controlled trials.

BACKGROUND: Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child wasting and stunting. There is little information regarding effects on severe wasting or stunting. OBJECTIVES: We aimed to identify the effect of SQ-LNSs on prevalence of severe wasting (weight-for-length z score < -3) and severe stunting (length-for-age z score < -3). METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age. We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS: SQ-LNS provision led to a relative reduction of 31% in severe wasting [prevalence ratio (PR): 0.69; 95% CI: 0.55, 0.86; n = 34,373] and 17% in severe stunting (PR: 0.83; 95% CI: 0.78, 0.90; n = 36,795) at endline. Results were similar in most of the sensitivity analyses but somewhat attenuated when comparisons using passive control arms were excluded (PR: 0.74; 95% CI: 0.57, 0.96; n = 26,327 for severe wasting and PR: 0.88; 95% CI: 0.81, 0.95; n = 28,742 for severe stunting). Study-level characteristics generally did not significantly modify the effects of SQ-LNSs, but results suggested greater effects of SQ-LNSs in sites with greater burdens of wasting or stunting, or with poorer water quality or sanitation. CONCLUSIONS: Including SQ-LNSs in preventive interventions to promote healthy child growth and development is likely to reduce rates of severe wasting and stunting. This meta-analysis was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.

Child dietary patterns in Homo sapiens evolution: A systematic review.

Dietary patterns spanning millennia could inform contemporary public health nutrition. Children are largely absent from evidence describing diets throughout human evolution, despite prevalent malnutrition today signaling a potential genome-environment divergence. This systematic review aimed to identify dietary patterns of children ages 6 months to 10 years consumed before the widespread adoption of agriculture. Metrics of mention frequency (counts of food types reported) and food groups (globally standardized categories) were applied to: compare diets across subsistence modes [gatherer-hunter-fisher (GHF), early agriculture (EA) groups]; examine diet quality and diversity; and characterize differences by life course phase and environmental context defined using Köppen-Geiger climate zones. The review yielded child diet information from 95 cultural groups (52 from GHF; 43 from EA/mixed subsistence groups). Animal foods (terrestrial and aquatic) were the most frequently mentioned food groups in dietary patterns across subsistence modes, though at higher frequencies in GHF than in EA. A broad range of fruits, vegetables, roots and tubers were more common in GHF, while children from EA groups consumed more cereals than GHF, associated with poor health consequences as reported in some studies. Forty-eight studies compared diets across life course phases: 28 showed differences and 20 demonstrated similarities in child versus adult diets. Climate zone was a driver of food patterns provisioned from local ecosystems. Evidence from Homo sapiens evolution points to the need for nutrient-dense foods with high quality proteins and greater variety within and across food groups. Public health solutions could integrate these findings into food-based dietary guidelines for children.

The Effects of 1 Egg per Day on Iron and Anemia Status among Young Malawian Children: A Secondary Analysis of a Randomized Controlled Trial.

Background: Young children with diets lacking diversity with low consumption of animal source foods are at risk of iron deficiency anemia (IDA). Objectives: Our objectives were to determine the impact of supplementing diets with 1 egg/d on 1) plasma ferritin, soluble transferrin receptor (sTfR), body iron index (BII), and hemoglobin concentrations and 2) the prevalence of iron deficiency (ID), anemia, and IDA. Methods: Malawian 6-9-mo-old infants in the Mazira trial (clinicaltrials.gov; NCT03385252) were individually randomly assigned to receive 1 egg/d for 6 mo (n = 331) or continue their usual diet (n = 329). In this secondary analysis, hemoglobin, plasma ferritin, sTfR, C-reactive protein (CRP), and α-1-acid glycoprotein (AGP) were measured at enrollment and 6-mo follow-up. Iron biomarkers were corrected for inflammation. Ferritin, sTfR, BII, and hemoglobin were compared between groups using linear regression. Prevalence ratios (PRs) for anemia (hemoglobin <11 g/dL) and ID (ferritin <12 µg/L, sTfR >8.3 mg/L, or BII <0 mg/kg) between groups were compared using log binomial or modified Poisson regression. Results: A total of 585 children were included in this analysis (Egg: n = 286; Control: n = 299). At enrollment, the total prevalence of anemia was 61% and did not differ between groups. At 6-mo follow-up, groups did not differ in geometric mean concentration of hemoglobin [mean (95% CI); Egg: 10.9 (10.7, 11.1) g/dL; Control: 11.1 (10.9, 11.2) g/dL] and inflammation-adjusted ferritin [Egg: 6.52 (5.98, 7.10) µg/L; Control: 6.82 (6.27, 7.42) µg/L], sTfR [Egg: 11.34 (10.92, 11.78) mg/L; Control: 11.46 (11.04, 11.89) mg/L] or BII [Egg: 0.07 (0.06, 0.09) mg/kg; Control: 0.07 (0.05, 0.08) mg/kg]. There were also no group differences in anemia [Egg: 46%; Control 40%; PR: 1.15 (95% CI: 0.96, 1.38)], ID [PR: 0.99 (0.94, 1.05)], or IDA [PR: 1.12 (0.92, 1.36)]. Conclusions: Providing eggs daily for 6 mo did not affect iron status or anemia prevalence in this context. Other interventions are needed to address the high prevalence of ID and anemia among young Malawian children. This trial is registered at http://www.clinicaltrials.gov as NCT03385252.

A sex- and gender-based analysis of factors associated with linear growth in infants in Ecuadorian Andes.

Although female infants may have an early life biological advantage over males, gendered treatment can alter health outcomes. Ecuador has an unusually high ratio of male to female infant mortality, but gender norms have been reported to favor boys. This analysis of baseline data from the Lulun Project, a randomized controlled trial conducted in rural Andean communities of Ecuador, investigates the roles of sex and gender in undernutrition among infants 6 to 9 months of age. Twenty-four-hour recall frequencies were used to assess dietary intake. Food outcome models were analyzed as prevalence ratios calculated using a binomial distribution with a log link or robust Poisson regression. Linear regression was used to analyze the continuous growth outcome length-for-age z score. Socioeconomic and health history variables were comparable between male and female infants. Boys were more often fed liquids other than breastmilk within their first 3 days of life (17.1% vs. 5.2%, P = 0.026). Compared with girls, boys were less likely to be fed eggs by 33% (95% CI 0.46, 0.96), cheese, yogurt, or other milk products by 40% (95% CI 0.39, 0.92), yellow fruit by 44% (95% CI 0.33, 0.97), water by 37% (95% CI 0.45, 0.88), thin porridge by 29% (95% CI 0.56, 0.92), and tea without milk by 67% (95% CI 0.11, 0.99). Prevalence of boys with an adequate dietary diversity score (≥ 4) was reduced by 27% relative to girls (95% CI 0.54, 0.99). Males fared worse in length-for-age z scores (- 2.16 vs. - 1.56, P = 0.000), weight-for-age z scores (- 0.86 vs. - 0.33, P = 0.002), prevalence of stunting (50.6% vs. 23.4%, P = 0.000), and plasma concentrations of dimethylglycine (1.25 vs. 1.65 µg/mL, P = 0.021). After adjusting for demographic, caregiver perceptions of appetite, and biological factors, length-for-age z score for a male child was 0.62 units lower than for a female (95% CI - 0.98, - 0.26). Male infants were shown to receive lower quality complementary foods and have worse anthropometric measures than female infants.Trial registration clinicaltrials.gov, NCT02446873. Registered February 28, 2015, https://clinicaltrials.gov/ct2/show/NCT02446873 .

Plasma Choline Concentration Was Not Increased After a 6-Month Egg Intervention in 6-9-Month-Old Malawian Children: Results from a Randomized Controlled Trial.

BACKGROUND: Eggs are a rich source of choline, an essential nutrient important for child growth and development. In a randomized trial of 1 egg/d in young children in Ecuador, an egg intervention led to significant improvements in growth, which were partially mediated by increased plasma choline concentration. A similar trial in Malawi (clinicaltrials.gov: NCT03385252) found little improvement in child growth or development. OBJECTIVES: We aimed to evaluate the effect of 1 egg/d for 6 mo on plasma choline concentrations in Malawian children enrolled in a randomized trial. METHODS: Infants aged 6-9 mo in rural Malawi were randomly assigned to receive 1 egg/d (n = 331) or serve as a nonintervention control (n = 329) for 6 mo. Anthropometric, developmental, and dietary data were collected at baseline and 6-mo follow-up, along with a blood draw. Plasma choline, betaine, dimethylglycine, trimethylamine N-oxide (TMAO), and DHA were measured at both time points using ultrahigh performance liquid chromatography-tandem MS (n = 200 per group). Linear regression analysis was used to determine the difference in plasma choline and related metabolites between groups after 6 mo of intervention. RESULTS: Plasma choline, betaine, dimethylglycine, and DHA concentrations did not differ between groups at 6-mo follow-up. Plasma TMAO was significantly (26%; 95% CI: 7%, 48%) higher in the egg intervention group in a fully adjusted model. CONCLUSIONS: Provision of 1 egg/d for 6 mo did not result in increases in plasma choline or related metabolites, except TMAO. This could partially explain the lack of effect on growth and development. Additional interventions are needed to improve choline status, growth, and development in this population.

Grandi Byen-supporting child growth and development through integrated, responsive parenting, nutrition and hygiene: study protocol for a randomized controlled trial.

BACKGROUND: Poor child growth and development outcomes stem from complex relationships encompassing biological, behavioral, social, and environmental conditions. However, there is a dearth of research on integrated approaches targeting these interwoven factors. The Grandi Byen study seeks to fill this research gap through a three-arm longitudinal randomized controlled trial which will evaluate the impact of an integrated nutrition, responsive parenting, and WASH (water, sanitation and hygiene) intervention on holistic child growth and development. METHODS: We will recruit 600 mother-infant dyads living in Cap-Haitien, Haiti and randomize them equally into one of the following groups: 1) standard well-baby care; 2) nutritional intervention (one egg per day for 6 months); and 3) multicomponent Grandi Byen intervention (responsive parenting, nutrition, WASH + one egg per day for 6 months). Primary outcomes include child growth as well as cognitive, language, motor, and social-emotional development. The study also assesses other indicators of child health (bone maturation, brain growth, diarrheal morbidity and allergies, dietary intake, nutrient biomarkers) along with responsive parenting as mediating factors influencing the primary outcomes. An economic evaluation will assess the feasibility of large-scale implementation of the interventions. DISCUSSION: This study builds on research highlighting the importance of responsive parenting interventions on overall child health, as well as evidence demonstrating that providing an egg daily to infants during the complementary feeding period can prevent stunted growth. The multicomponent Grandi Byen intervention may provide evidence of synergistic or mediating effects of an egg intervention with instruction on psychoeducational parenting and WASH on child growth and development. Grandi Byen presents key innovations with implications for the well-being of children living in poverty globally. TRIAL REGISTRATION: NCT04785352 . Registered March 5, 2021 at https://clinicaltrials.gov/.

Aquatic Animal Foods for Nutrition Security and Child Health.

BACKGROUND: Aquatic animal source foods (AASF) can provide vital nutrients and bioactive factors essential for human health, yet disparities in consumption patterns prevail globally. Limited evidence exists for the implications of AASF access on child health outcomes. OBJECTIVE: This study aimed to examine global AASF intakes longitudinally in association with critical nutrient intakes and childhood stunting and anemia. METHODS: The analysis draws from compiled longitudinal country data (1993-2013) based on a constructed conceptual framework encompassing social and ecological factors that influence fish consumption and human health. Longitudinal generalized linear models were used to estimate the association of apparent AASF intake on country-level nutrient availability (docosahexaenoic acid [DHA], choline, vitamin B12, iron, and zinc) and prevalence of undernourishment, child stunting, and child anemia. RESULTS: Across 175 countries, the median per capita daily apparent intake of all AASF was 37.87 g, with marginally significant differences observed between countries with low (46.65 g) versus high child mortality (23.50 g). The combined category of all AASF was significantly associated with increased total apparent intakes of DHA, choline, and vitamin B12 and reduced child stunting. Finfish (pelagic and demersal) and crustaceans inversely correlated with child stunting, while apparent intakes of mollusks and crustaceans were associated with reduced child anemia. CONCLUSIONS: This study uniquely showed that AASF were associated with improved child health outcomes and the critical nutrients necessary for growth, development, and maintaining health throughout the life course. Policies should ensure increased access to AASF across food systems and within sustainable healthy diets globally.

Small-quantity lipid-based nutrient supplements for children age 6-24 months: a systematic review and individual participant data meta-analysis of effects on developmental outcomes and effect modifiers.

BACKGROUND: Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development. OBJECTIVES: We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects. METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024). RESULTS: In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11). CONCLUSIONS: Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42020159971.

Characteristics that modify the effect of small-quantity lipid-based nutrient supplementation on child growth: an individual participant data meta-analysis of randomized controlled trials.

BACKGROUND: Meta-analyses show that small-quantity lipid-based nutrient supplements (SQ-LNSs) reduce child stunting and wasting. Identification of subgroups who benefit most from SQ-LNSs may facilitate program design. OBJECTIVES: We aimed to identify study-level and individual-level modifiers of the effect of SQ-LNSs on child growth outcomes. METHODS: We conducted a 2-stage meta-analysis of individual participant data from 14 randomized controlled trials of SQ-LNSs provided to children 6-24 mo of age (n = 37,066). We generated study-specific and subgroup estimates of SQ-LNS compared with control and pooled the estimates using fixed-effects models. We used random-effects meta-regression to examine study-level effect modifiers. In sensitivity analyses, we examined whether results differed depending on study arm inclusion criteria and types of comparisons. RESULTS: SQ-LNS provision decreased stunting (length-for-age z score < -2) by 12% (relative reduction), wasting [weight-for-length (WLZ) z score < -2] by 14%, low midupper arm circumference (MUAC) (<125 mm or MUAC-for-age z score < -2) by 18%, acute malnutrition (WLZ < -2 or MUAC < 125 mm) by 14%, underweight (weight-for-age z score < -2) by 13%, and small head size (head circumference-for-age z score < -2) by 9%. Effects of SQ-LNSs generally did not differ by study-level characteristics including region, stunting burden, malaria prevalence, sanitation, water quality, duration of supplementation, frequency of contact, or average compliance with SQ-LNS. Effects of SQ-LNSs on stunting, wasting, low MUAC, and small head size were greater among girls than among boys; effects on stunting, underweight, and low MUAC were greater among later-born (than among firstborn) children; and effects on wasting and acute malnutrition were greater among children in households with improved (as opposed to unimproved) sanitation. CONCLUSIONS: The positive impact of SQ-LNSs on growth is apparent across a variety of study-level contexts. Policy-makers and program planners should consider including SQ-LNSs in packages of interventions to prevent both stunting and wasting.This trial was registered at www.crd.york.ac.uk/PROSPERO as CRD42019146592.